Radar on Medicare Advantage

As Congress considers expanding Medicare benefits through the budget reconciliation process, a new HHS report expresses the agency’s support for “bold legislative action” to bring down drug prices and outlines a “comprehensive” plan that includes several administrative actions it could take to promote competition among drug companies. Notably, the report calls for legislation allowing HHS Secretary Xavier Becerra to directly negotiate drug prices with manufacturers for coverage under the Medicare Parts B and D programs and to make those prices available to other payers, and the exploration of various concepts by the CMS Innovation Center.

The HHS Office of the Assistant Secretary for Planning and Evaluation on Sept. 9 issued the report in response to President Joe Biden’s Executive Order on Promoting Competition in the American Economy, which called for a multitude of actions from HHS, including lowering the prices of and improving access to prescription drugs and biosimilars. Meanwhile, lawmakers are considering adding dental, hearing and vision benefits to fee-for-service Medicare as part of a $3.5 trillion spending package that Senate Democrats aim to pass via budget reconciliation, and drug pricing has been viewed as a way to pay for those enhancements.

by Carina Belles

Enrollment in Employer Group Waiver Plans (EGWPs) grew 19.5% from 2018 to 2021, at an average rate of about 6% per year, according to the August 2021 update to AIS’s Directory of Health Plans. About 18% of all Medicare Advantage members are enrolled in an EGWP, with UnitedHealthcare, CVS Health Corp.-owned Aetna and Kaiser Permanente leading the market. Overall, the top 10 payers have an iron grip on market share, enrolling 92.7% of all EGWP members.

Hoping to boost enrollment in the struggling Medicare Diabetes Prevention Program (MDPP) expanded model, CMS has proposed changes that would increase reimbursement and significantly shorten the services period for participants. While stakeholders agree that the changes are needed, some warn they’re only incremental steps to shore up the MDPP, which has faced a shortage of suppliers and challenges posed by the requirement that the program be delivered to beneficiaries in person.

“The MDPP rules and regulations, including the payment mechanism and the two-year commitment — in contrast to one year for the CDC DPP [U.S. Centers for Disease Control and Prevention Diabetes Prevention Program] — have made enrollment very difficult if not impossible for MDPP suppliers,” asserts Liz Joy, M.D., senior medical director for wellness and nutrition at Intermountain Healthcare.

✦ In the latest False Claims Act settlement involving allegations of Medicare Advantage “upcoding,” Sutter Health and its affiliates agreed to pay $90 million to resolve claims that they knowingly submitted inaccurate information about the health status of beneficiaries enrolled in MA plans. Those claims were initially raised in a whistleblower lawsuit (U.S. ex rel. Ormsby v. Sutter Health, et al., No. 15-CV-01062-LB), filed by a former employee of Palo Alto Medical Foundation, an entity affiliated with Sutter Health. According to the Dept. of Justice’s complaint-in-intervention, the federal government alleged that the health system submitted unsupported diagnosis codes for certain patient encounters, causing inflated payments to be made to the MA plans covering those beneficiaries and to Sutter Health. The lawsuit also alleged that, once the provider organization became aware of these unsupported diagnosis codes, it “failed to take sufficient corrective action to identify and delete additional unsupported diagnosis codes.”

✦ The House on Aug. 24 approved President Joe Biden’s multimillion-dollar fiscal blueprint, paving the way for legislators to draft the Build Back America plan this fall. The Senate in August passed the $3.5 trillion resolution framework, which included expanding Medicare benefits, lowering the Medicare eligibility age, and enhancing funding for Medicaid Home and Community-Based Services. The resolution provided a target date of Sept. 15 for the Senate committees to submit their reconciliation legislation. Meanwhile, Wakely estimated that the addition of hearing, dental and vision benefits in Medicare would result in a per-beneficiary reduction of about $696 to $1,056 a year in added benefits if Medicare Advantage rates aren’t adjusted. If Congress adds these benefits to Original Medicare without adjusting the MA benchmark, plans would have an average of 48% to 73% fewer rebate dollars to fund supplemental benefits such as transportation, meals, in-home services and supports, and over-the-counter medicines, according to the report prepared for AHIP.

If a recent slew of press releases is an early indication, insurers are intent on growing their Medicare Advantage business in 2022 through expansions into largely untapped areas and strategic partnerships with locally recognized providers. All service area expansions are subject to CMS approval. The 2022 Annual Election Period begins on Oct. 15 and runs through Dec. 7.

Anthem, Inc. this fall will partner with Kroger Health to offer an MA plan in four regions: Atlanta, Cincinnati, Louisville, Ky., and southern Virginia. During the company’s July 21 second quarter earnings call, President and CEO Gail Boudreaux said MA “remains a key area of focus” for the organization. Further boosting its MA business, Anthem recently acquired Puerto Rico Medicaid and MA plan operator MMM, and the company won a contract to serve New York City retirees next year (see story, p. 1).